Archive for October, 2013

There continues to be considerable controversy over the extent of Lyme Disease in the United States. Its cause is a spirochete, a skinny, long bacteria that is coiled and looks like a microscopic spring. Historically this family of "bugs" was known to have a member that caused syphilis, a scourge of mankind for thousands of years. Then in 1975 a new disease made its first appearance with a cluster of cases in both children and adults in Lyme, Connecticut. Over fifty cases were reported in the first two years of the epidemic, the black-legged tick Ixodes scapularis was found to be the vector that transmits the disease to humans and in 1982 the spirochete Borrelia burgdorferi was identified as the bacteria responsible for the rash, arthritis, cardiac and neurological manifestations of what was eventually termed Lyme disease. The World Health Organization calls the illness Lyme borreliosis and it is widely found in Europe from Turkey to Sweden with nearly 65,000 cases a year, some differences in signs and symptoms and another tick species as the transmitting agent.

Lyme disease has clearly spread from its origin in the northeast US and is now an illness that affects hundreds of thousands yearly. The Center for Disease Control and Prevention (CDC) has a website with extensive information on Lyme Disease, and links to frequently asked questions about the illness. Among those bits of information is the blunt statement that Lyme disease, to a great extent, only occurs in three endemic regions of this country. Those cases occur in the area from northeast Virginia to Maine and some north-central states, including Wisconsin and Minnesota.

But it also can be spread by another tick much further west, especially in California where a different black-legged tick, Ixodes pacificus is the vector. And the CDC's own interactive map of Lyme disease cases from 2001 through 2012 shows it has struck in Florida, Texas and a number of other states, albeit without the number of cases seen in the east and northeast portions of this country.

Humans aren't the only species affected; dogs can get Lyme disease also and the incidence of the illness has markedly increases. A canine vaccine is available. Horses, cattle and cats can also get Lyme, but much less commonly.

A major issue is whether Lyme disease or something quite similar occurs in the South. The debate on that started twenty-five years ago and continues to today.

In 1988, Dr. Edwin Masters, a family practice physician in Missouri and amateur forester, gave a talk on Lyme disease to a forestry association. He had extensively prepared for his lecture and subsequently began to see cases of what he thought was Lyme disease in his own practice. Many had a rash similar to Lyme victims elsewhere (erythema migrans, abbreviated as EM). Some had swollen joints, neurological signs and symptoms and positive blood tests for Lyme disease using the test most commonly available then. Masters reported his cases to the Missouri Department of Health, but found that his reports were ignored.

He didn't give up at that point, but carefully photographed the EM rashes his patients presented with and stored blood samples. In the North the CDC said just having the reach was diagnostic, but denied that was true in the South.

A 1999 paper published by scientists from Amsterdam and New York said that there are ten different species of the spirochete bacteria that is called Borrelia. At that time three were known to cause disease in humans.

A multi-part 2009 blog post in Psychology Today's Emerging Diseases series (written by Pamela Weintraub, the Executive Editor at Discover Magazine) was titled "Rebel with a Cause: The Incredible Dr. Masters." It details the last thirty years of the live of the physician who championed the cause of Southern Lyme disease.

The Lone Star tick appears to be the vector for Lyme-like diseases in the South.

A 2013 Discover Magazine In-Depth report Ticked: The battle over Lyme Disease in the South, tells the story well (I downloaded it for $1.99). In brief, many people who live in the South have had a Lyme-like illness that the Lyme and Tick-Borne Diseases Research Center at Columbia University calls STARI, Southern Tick-Associated Rash Illness. From the CDC's conservative viewpoint this is not Lyme Disease since it has never been clearly proven to be caused by the spirochete Borrelia burgdorferi sense stricto (that translates to "In the strict sense") and, according to the CDC doesn't cause the major complications associated with that illness. Their 2011 webpage on STARI says patents bitten by the Lone Star tick can sometimes develop an EM rash like those of Lyme disease victims, but the skin manifestations of STARI are slightly different and arthritis, cardiac or neurological complications don't occur.

Kerry Clark, a PhD associate professor in the Department of Public Health at the University of South Florida, took up the cudgel for Southern Lyme disease after Masters' death. He is a medical entomologist at USF who had collected and studied ticks for years. After giving a Lyme disease talk in Georgia three years ago, he was approached by a woman from an Atlanta suburb who told him there were many similar cases in her town. Clark collected many ticks from the patchy woodland areas infiltrating the area; most were juvenile (nymph phase) or adult Lone Star ticks.

Several days later he found one engorged tick on his own scalp. Since he has had fatigue, intermittent mental "fuzziness," twitches and a strange recurrent pounding headache.

Clark recently published a major study in the International Journal of Medical Sciences (easily available on the National Library of Medicine website) with the title "Lyme Borreliosis in Human Patients in Florida and Georgia, USA." It gives demographic, clinical and lab data on ten such patients with suspected Lyme disease. Clark and his associates used a newly developed test developed specifically for the genospecies Borrelia burgdorferi. Worldwide this includes more than 20 different "bugs" with seven in North America, but in the past only one had been generally accepted as responsible for Lyme disease. With DNA confirmation, they reported finding other closely-related spirochetes in patients' blood and skin as well as in Lone Star ticks.

My first take was this was an impressive article, but I am aware of those who would treat many patients with a variety of symptoms for "chronic Lyme disease" over extended periods of time using repeated doses of expensive intravenous antibiotics. And there is another subset of physicians, including, unfortunately, one of Clark's co-authors, who use treatment modalities which I view with great skepticism.

If other academic laboratories confirm Clark's work, perhaps we can get to definitive answers and make available tests that help determine when and how to treat patients with atypical Lyme disease.

Having seen diagnoses come and go (e.g., the virus that supposedly caused chronic fatigue syndrome was eventually found to be a lab contaminant), I'm waiting for those confirmatory studies.

babesiosis, caused by the parasite Babesia microti —

a pathogen similar in type and impact to the one that causes

malaria. Ticks in the South also carry other diseases, including

Rocky Mountain Spotted Fever and ehrlichiosis, caused by two

kinds of related bacteria.

The Columbia University Lyme and Tick-borne Disease Research Center's website has a nicely balanced discussion of STARI, Southern Tick-Associated Rash Illness, sometimes called Masters Disease in honor of the now-deceased Missouri family physician who initially reported cases of what was felt to be a Lyme Disease-like illness.

Discover magazine, which I subscribe to, has an In-Depth publication available for $1.99 on the controversy concerning a Lyme disease-like illness in the south. It's well written by Wendy Orent, a PhD anthropologist/science writer who teaches at Emory University; she has also published a controversial book on plague.

Orent was also involved in a debate about the possibility of an H5N1 (bird flu) epidemic. According to Orent, there was no legitimate basis to assume that any large-scale epidemic would ensue as a result of the H5N1 virus.

My wife and I are supporters of two art museums, one locally and the other in Denver. I also have a personal interest in eye problems, especially cataracts and macular disease, as my father had lost an eye as an intern (a paper cut led to an infection and, in those days, before antibiotics, there was concern about the other eye developing problems, a medical issue called sympathetic ophthalmia). In his late 80s he had a cataract in his remaining eye and, when he was examined by an ophthalmologist at the Cleveland Clinic, was found to have macular degeneration, a chronic eye disease usually seen in people over 50.

Someday my visions may deteriorate to this point.

I became aware, as I read about Dad's problem, that one day it might become mine as well; one of the risk factors for macular degeneration is a family history of the disease.

I've pasted in a list of symptoms from this condition (copied from a Mayo Clinic website).

The need for brighter light when reading or doing close work

Increasing difficulty adapting to low light levels, such as when entering a dimly lit restaurant

Increasing blurriness of printed words

A decrease in the intensity or brightness of colors

Difficulty recognizing faces

A gradual increase in the haziness of your central or overall vision

Crooked central vision

A blurred or blind spot in the center of your field of vision

Hallucinations of geometric shapes or people, in case of advanced macular degeneration

The National Eye Institute, a branch of the NIH, has a fact sheet on age-related macular degeneration (AMD) that's worth looking at if you or someone in your family develops this problem. I'll mention a few things from that website as AMD is a major cause of vision loss in older adults. To begin with the macula is the part of your eyes that gives you the sharpest, most detailed vision. It's the extremely sensitive part of the retina, the layer of tissue at the back of your eye that responds to light, converting images, focused by the eye's lens on this equivalent of camera film, into electrical signals that travel via the optic nerve to the brain. If the macula is damaged, fine points of these images become less clear.

If this happens to a non-artist, someone who doesn't make their living through images they put into a form that others can enjoy, it still leads to less sharp vision. You may have problems reading, driving or recognizing an image such as a face. Since your peripheral vision isn't affected, you'll probably be able to walk around without major difficulty.

But image that you're an artist. You gradually realize your vision is becoming less clear. You used to be able to read an eye chart at the 20/20 level, meaning you can read the same row of small letters on the chart at 20 feet which those with normal vision can. Now your visual acuity, measured when you see your eye specialist, is slipping and you worry that it will affect your ability to paint as well as you once did.

Having 20/20 eyesight does not necessarily mean perfect vision. 20/20 vision only indicates the sharpness or clarity of vision at a distance. There are other important vision skills, including peripheral awareness or side vision, eye coordination, depth perception, focusing ability and color vision that contribute to your overall visual ability.

Some people can see well at a distance, but are unable to bring nearer objects into focus. This condition can be caused by hyperopia (farsightedness) or presbyopia (loss of focusing ability). Others can see items that are close, but cannot see those far away. This condition may be caused by myopia (nearsightedness).

I've written about these medical problems before, but was riveted by a pair of articles I found in two AMA publications yesterday. A Stanford eye surgeon, Dr. Michael F. Marmor, just published a supurb article on Edgar Degas' progressive loss of vision in his later years. Degas was born in Paris in 1834 and died there in 1917. His painting altered from 1860 , when he had essentially normal vision, to 1870 and beyond when first one eye, then the other progressively lost visual acuity. By 1897 he was seeing at a 20/200 level; that means he could would have to be twenty feet away from an eye chart to read the letters that someone with normal vision could read from 200 feet away.

The style and details of his paintings, especially his pastels, have been shown to change as Degas' eye problems progressed, but Dr. Marmor's article calls our attention to one oil painting, Scene from the Steeplechase: The Fallen Jockey. Here's a link to the painting in the National Gallery of Art; it was originally painted in 1866 and reworked by the artist in 1880-81 and again in 1896 with considerable changes made which Dr. Marmor shows can be linked to Degas' declining visual acuity.

A number of other significant artists have demonstrated visual loss in their work. An April, 2007 article in ScienceDaily focuses on Dr. Marmor's work, mentioning he's authored two books on art and eye sight: Degas Through His Own Eyes and The Artists's Eye (I've ordered a copy of the latter book through Amazon).

The Blind with Camera School of Photography website mentions a number of other famous figures from the art world who struggled with visual issues. Among those were El Greco, Rembrandt, Van Gogh, Paul Cezanne, Claude Monet, Mary Cassatt, Camille Pissarro and Auguste Renoir. Georgia O'Keeffe, who lived to the age of 98, also suffered with significant eye disease in her later years; her almost complete loss of eyesight and ill health during the last fifteen years of her life significantly curtailed her artistic productivity. Her eye problems began in 1968, and by 1971 macular degeneration caused her to lose all her central vision.

How is this honeybee similar to Monet?

Monet had cataracts which not only diminished his visual acuity, but also affected his perception of colors. He resisted having surgery, but eventually decided to have one cataract removed. After the operation, according to science writer Carl Zimmer's review of the San Francisco Exploratorium's free publication, Color Uncovered, Monet, like honeybees, was able to see ultraviolet light (normally filtered out by the lens of your eye) and painted water lilies a pale blue. Bees are guided to pollen by light signals we are unable to perceive; Monet had lost a lens to surgery, but gained a spectrum of light perception the rest of us lack.

I have zero talent as a visual artist, but after bilateral cataract surgery my vision is correctable to 20/20...for now.

I recently heard from Kevin Thompson, a Colorado blogger who read one of my posts and wondered if I'd include a link to one of his on my website. I knew of tree nut allergies only in the most general terms, but found his post gripping and, for parents of a child with nut allergies, potentially life-saving.

But I wanted to do some reading on the subject myself and also needed to see what else Kevin had posted on his blog.

Before I move on to his recent ideas on nut allergies, I'd like to mention (and give you a link to) another of Kevin's posts, "10 of the Most Common Food Allergies in Kids." In that one he discusses, in non-technical terms, children's alleges to eggs, milk, soy, wheat, peanuts, tree nuts, fish, shellfish, strawberries and (amazingly) kiwi fruit.

The American Academy of Pediatrics website has a July, 2013 update on diagnosing food allergies in children. That post mentions the most common pediatric food allergies are to dairy products, egg whites, poultry, seafood, wheat, nuts, soy and chocolate. Like any kind of allergy, those to food happen when your immune system, reacting to a substance foreign to your body, produces antibodies, chemicals that usually help to protect you from infections, or as the Mayo Clinic website on allergies says, "unwanted invaders that could make you sick."

The reaction from your immune system leads to inflammation, but the area affected and the seriousness of the reaction varies. What Kevin was talking about is the high end of the spectrum, those forms of allergic responses that can be life-threatening.

Some years back a nurse at the allergy clinic my wife goes to (fifty miles north of us in Cheyenne, Wyoming), asked if someone in the home could give Lynnette her allergy shots. That would mean she didn't have to drive a hundred miles every other week. I was drafted although I had never given shots in my years as a practicing physician. I learned quickly; after all I had performed kidney biopsies and, in my early days in nephrology, stuck large needles into arteries when a patient had acute kidney failure and needed dialysis.

But I needed some onsite drugs in case Lynnette had a medium or, heaven forbid, a major reaction to the allergy shots.

Here's what an EpiPen looks like.

I purchased some over-the-counter Benadryl and our family practice physician wrote us a prescription for epinephrine in the form of an EpiPen (there are other brands). This is an auto-injector, something you slam into the outer thigh of a person having a really serious allergic response to a foreign substance (i.e., an allergen) or to exercise or for unknown reasons. It's available in an adult form with 0.3 milligrams of epinephrine or in a half dose (EpiPen Jr) and I purchased a two-pack that came with a training device.

I hadn't tried that before today, so I just got it out of its box and followed the instructions. I removed the Blue Safety Release, swung the device against my outer thigh and pushed it, hearing a click that, with the actual EpiPen would have meant a needle had extended and, while I held it against my thigh for ten seconds, would have injected me with the (hopefully) life-saving medicine. I would have been comfortable using the actual EpiPen, but thought I should simulate a non-medically-trained person practicing how they would use the real thing.

I hadn't mentioned it yet, but you don't take the time to lower the trousers of the person (whether that's you or someone else) having serious allergic problems to use the EpiPen; it goes right through the cloth in the event of a life-threatening emergency. It does have a needle and it does contain the epinephrine to counteract a major allergic reaction.

The Trainer doesn't contain any medication and has no needle; it's also reusable, so somebody can practice with it until they are comfortable with the procedure.

Why in the world would you do this to yourself or someone else? The website of the American Academy of Allergy Asthma and Immunology describes this condition, medically termed anaphylaxis, as a serious, life-threatening allergic reaction, mostly commonly seen with foods, insect stings, medications and latex exposure. The signs and symptoms typically involve more than one part of the body . They require an immediate injection of epinephrine and a trip to the emergency room (call 911, don't drive the person yourself).

Most commonly, anaphylaxis starts within a few minutes (five to thirty) after exposure to the allergen (the substance to which the person is allergic). It can lead to any combination of: hives, swelling in the throat or elsewhere, wheezing, difficulty swallowing, trouble breathing, a feeling of tightness in the chest, syncope (fainting), vomiting and/or diarrhea with cramps, a feeling of impending doom and/or paleness or redness of the body or face.

Occasionally it can have a delayed start, so I had my wife practice with the EpiPen Trainer also just in case I've left the house after I'd given her the shots, waited fifteen minutes to check the areas where they went in (one on each arm), and recorded the local reaction or lack thereof.

So let's go back to Kevin Thompson's blog post, "How to Keep a Child With Nut Allergies Safe at School."It walks you, as a parent, step by step, through the means to safeguard your child's health after they have been diagnosed with an allergy to nuts (tree nuts or peanuts). I think it's well worth reading if you have a youngster with those kinds of potentially fatal allergic problems. From approaching the school's personnel, to helping the child her- or himself be knowledgable, to ensuring the teachers and others at the school are prepared to deal with an anaphylactic reaction, to considering other options, the post is something I'd recommend you print multiple copies of and pursue with due diligence.

It's best to be prepared and even over-prepared for a life-threatening situation.